RSL War Veterans Home Mandurah - Aged Care Quality€¦ · RSL War Veterans Home Mandurah 7154...

RSL War Veterans Home Mandurah

RACS ID 7154 82 Oakmont Avenue

MANDURAH WA 6210

Approved provider: The RSL Care WA Retirement and Aged Care Association Incorporated

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 13 October 2018.

We made our decision on 28 August 2015.

The audit was conducted on 22 July 2015 to 23 July 2015. The assessment team’s report is attached.

We will continue to monitor the performance of the home including through unannounced visits.

Home name: RSL War Veterans Home Mandurah RACS ID: 7154 2 Dates of audit: 22 July 2015 to 23 July 2015

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

Expected outcome Quality Agency decision

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met


Standard 2: Health and personal care

Principle:

Care recipients' physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team.





2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


Standard 3: Care recipient lifestyle

Principle:

Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care service and in the community.





3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Care recipient security of tenure and responsibilities

Met

Standard 4: Physical environment and safe systems

Principle:

Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.





4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


Audit Report

RSL War Veterans Home Mandurah 7154


Introduction

This is the report of a re-accreditation audit from 22 July 2015 to 23 July 2015 submitted to the Quality Agency.

Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to care recipients in accordance with the Accreditation Standards.

To remain accredited and continue to receive the subsidy, each home must demonstrate that it meets the Standards.

There are four Standards covering management systems, health and personal care, care recipient lifestyle, and the physical environment and there are 44 expected outcomes such as human resource management, clinical care, medication management, privacy and dignity, leisure interests, cultural and spiritual life, choice and decision-making and the living environment.

Each home applies for re-accreditation before its accreditation period expires and an assessment team visits the home to conduct an audit. The team assesses the quality of care and services at the home and reports its findings about whether the home meets or does not meet the Standards. The Quality Agency then decides whether the home has met the Standards and whether to re-accredit or not to re-accredit the home.

Assessment team’s findings regarding performance against the Accreditation Standards

The information obtained through the audit of the home indicates the home meets:

44 expected outcomes


Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 22 July 2015 to 23 July 2015.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of two registered aged care quality assessors.

The audit was against the Accreditation Standards as set out in the Quality of Care Principles 2014.

Assessment team

Team leader: Philippa Brittain

Team member: Janice Rooney

Approved provider details


Details of home

Name of home: RSL War Veterans Home Mandurah

RACS ID: 7154

Total number of allocated places:

55

Number of care recipients during audit:

54

Number of care recipients receiving high care during audit:

47

Special needs catered for: Nil specified

Street: 82 Oakmont Avenue

City: MANDURAH

State: WA

Postcode: 6210

Phone number: 08 9535 0200

Facsimile: 08 9535 0202

E-mail address: [email protected]

http://www.comlaw.gov.au/Details/F2011L00821

mailto:[email protected]


Audit trail

The assessment team spent two days on site and gathered information from the following:

Interviews

Category Number

Facility manager 1

Acting general manager 1

Clinical lead nurse 1

Registered and enrolled nurses 2

Care staff 9

Administration assistants 2

Catering staff 2

Care recipients/representatives 13

Physiotherapist 1

Occupational therapist 1

Therapy staff 2

Laundry staff 2

Cleaning staff 2

Maintenance staff 1

Sampled documents

Category Number

Care recipients’ assessments, care plans and progress notes 6

Care recipients files 8

Self-medicating authorisations 1

Care recipients’ agreements 2

Personnel files 6

Medication profiles and signing sheets 6

Care recipients’ individual therapy programs 8

Care recipients’ weight records 12

Care recipients’ blood glucose monitoring 2


Other documents reviewed

The team also reviewed:

“Tell us what you think forms”

Accidents/incidents and hazards

Audits internal and external, surveys and action plans

Care recipient dietary requirements/drinks lists/nutritional supplements

Care recipients’ information package and handbook

Clinical audits and results

Communication books and dairies

Continuous improvement plan

Fire detection and firefighting systems maintenance reports

Food safety records file, and third party audit and inspection

Handover sheets

Human resource matrices including police certificates, visa limitations, professional registrations and performance appraisals

Job descriptions and duty statements

Laundry and cleaning folders

Medication policy and competency

Meeting minutes

Memoranda

Menu and care recipients’ dietary information

Pessary competency

Policies and procedures

Preventative and corrective maintenance records

Referral documentation

Restraint monitoring file

Roster

Smoking risk assessments


Staff handbook

Suppository competency

Therapy monthly activity planners

Training and education documentation

Training planner and records file, and monitoring matrix.

Observations

The team observed the following:

Access to complaints mechanisms and external sources of advice

Activities in progress

Assistive crockery and cutlery in use

Care recipients’ general appearance

Charter of residents’ rights and responsibilities

Emergency procedures

Equipment and supply storage areas including mobility equipment, oxygen, continence aids, clinical equipment and food stores

Interactions between staff and care recipients

Living environment

Meal and refreshment services

Noticeboards, and care recipient and staff information

Personal protective equipment, anti-bacterial gels, and sharps disposal

Safety data sheets

Small group observation in dining area

Storage of medications.


Assessment information

This section covers information about the home’s performance against each of the expected outcomes of the Accreditation Standards.

Standard 1 – Management systems, staffing and organisational development

Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

1.1 Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings

The home meets this expected outcome

The home has systems and processes to demonstrate a commitment to continuous improvement across the four Accreditation Standards. Comments, complaints and suggestions, audits, incidents, meetings and informal observations identify opportunities for improvement. The manager oversees improvement projects at the home and delegates where necessary. Identified projects are added to the continuous improvement plan for implementation, monitoring and evaluation. Continuous improvement is discussed at meetings and information is provided to staff, care recipients and representatives through meetings held at the home. Care recipients and representatives reported management is responsive to comments and suggestions. Staff gave examples of improvements recently completed that have assisted them in their role.

Examples of recent improvements in relation to Standard 1 – Management systems, staffing and organisational development are described below.

Management reported, following feedback from staff, a handover sheet was created as a communication tool for all staff to read regarding care recipients’ care services. Staff stated the handover sheet had improved communications and they are kept well informed.

Management and staff identified care recipients’ assessments were not always current despite a schedule in place. As a result, a study day provided staff information on how and why assessments are conducted. Staff reported, and documentation confirmed, assessments are up-to-date and management reported the study will be an ongoing annual training event.


1.2 Regulatory compliance

This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”.

Team’s findings


The home uses the organisation’s systems and processes to ensure the identification of, and compliance with, relevant legislation. The organisation receives updates on legislative and regulatory changes from peak bodies and other government and non-government agencies, and policies are updated accordingly. The manager is notified of any changes and advises staff as required via meetings, memoranda and education. There are processes to monitor statutory declarations, police certificates and professional registrations for all staff, this includes appropriate certificates for volunteers and external contractors. Care recipients, representatives and staff have access to internal and external complaints and advocacy information. Management monitors compliance with legislation and the home’s policies and procedures via an auditing program, external inspections, and human resource and operational processes. Care recipients and representatives were informed of the re- accreditation audit via correspondence, newsletters and posters displayed around the home.

1.3 Education and staff development

This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”.

Team’s findings


The organisation’s education program ensures management and staff have appropriate knowledge and skills to perform their roles effectively. Management identify training needs through feedback and requests from staff, satisfaction surveys, audits, accident/incident reports and observation of work practices. Site orientation and super numerary shifts are established for new staff, and induction, mandatory and optional training is accessed via internal, external and online mediums. Evaluation of the effectiveness of training is monitored via staff feedback and recording of staff attendance. Staff reported they have access to a variety of internal and external training and education opportunities. Care recipients and representatives reported management and staff are knowledgeable and perform their roles effectively.

Examples of education and training related to Standard 1 – Management systems, staffing and organisational development are listed below.

Complaints management

Continuous improvement

Corporate orientation and mandatory training.


1.4 Comments and complaints

This expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms".

Team’s findings


The home has processes to ensure care recipients, representatives and other stakeholders have access to internal and external comments and complaints mechanisms. The home provides confidential and secure avenues for submitting anonymous feedback forms. The home displays information on the processes to access internal and external complaints and advocacy services, and discuss the comments and complaints process with care recipients and their representatives on moving into the home, at care recipient/representative meetings and in case conferences. The home measures the effectiveness of the comments and complaints process via satisfaction surveys and identified trends feed into the home’s continuous improvement plan. Staff receive information about the home’s comments and complaints process during orientation and advocate on behalf of care recipients as required. Care recipients and representatives reported satisfaction with access to the complaints mechanisms.

1.5 Planning and leadership

This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service".

Team’s findings


The organisation has documented its vision, mission and values statement along with the commitment to quality statement in the home’s information systems. The statements are displayed around the home. These are communicated within the care recipient and staff information handbooks.

1.6 Human resource management

This expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives".

Team’s findings


The home has access to appropriately skilled and qualified staff to ensure services are delivered in accordance with care recipients’ needs. Management reviews staffing levels based on care recipients’ care needs and feedback from stakeholders. The home uses organisational processes to recruit and roster staff, and relevant staff monitor staff working visas and professional registrations for currency as appropriate. Staff performance is monitored via performance appraisals and feedback mechanisms, surveys and audits. Staff reported they have sufficient time to complete their duties and have the appropriate skills to conduct their roles. Relief cover is provided from casual staff and temporary staff, and a registered nurse is on call weekends and after hours. Care recipients and representatives


generally reported satisfaction with the skill level and number of staff in place to provide adequate care.

1.7 Inventory and equipment

This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available".

Team’s findings


There are systems and processes to ensure appropriate stocks of goods and equipment are available for quality service delivery. The home has ordering and stock management systems for goods, supplies and equipment. Therapy staff review the use of suitable aids and equipment for care recipients, and make recommendations to purchase equipment to meet care recipients’ needs. There are maintenance programs for relevant equipment, the buildings and grounds. Staff receive training for appropriate use of care and mechanical equipment. Staff reported they have enough equipment and supplies to undertake their tasks. Care recipients and representatives reported general satisfaction with the availability and suitability of goods and equipment provided to care recipients.

1.8 Information systems

This expected outcome requires that "effective information management systems are in place".

Team’s findings


The home has management systems to allow for an effective flow of information including the collection, analysis and dissemination of information related to residential care, business and operational matters. Management routinely collate, analyse/review and discuss at quality meetings information from clinical records and indicators, monitoring and reporting mechanisms and operational processes. The home schedules meetings specific to roles and groups, and minutes are available for review. There are procedures for storage and maintaining security of information via archiving and back-up of computerised data. Staff reported they have access to accurate information made available to them, receive memoranda and notices, attend regular meetings/handovers, and have access to feedback and reporting mechanisms. Care recipients and representatives reported general satisfaction with the access to information relevant to them, including activities and events of the home.

1.9 External services

This expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals".

Team’s findings


The organisation has processes to ensure the provision of externally sourced services meets the home’s needs and service requirements. The organisation identifies externally sourced services in response to regulatory requirements, licensing and specified care services, and the home accesses local externally sourced services whenever appropriate. The home has specific agreements with the service providers that set out criteria and regulatory


requirements. Management and relevant staff monitor the level of performance, and stakeholders use feedback mechanisms to raise issues about the quality of external services as appropriate. The organisation’s management reviews the services required from, and the quality goals for, external service providers in response to changes. Care recipients, representatives and staff reported satisfaction with externally sourced services.


Standard 2 – Health and personal care

Principle: Care recipients’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each care recipient (or his or her representative) and the health care team.



Team’s findings


Refer to expected outcomes 1.1 Continuous improvement for an overview of the home’s continuous improvement systems and processes.

In relation to Standard 2 – Health and personal care, staff record care recipient accidents and incidents, and this information is collated and analysed for trends. Clinical audits are conducted to measure and review the clinical care systems. Care recipients and staff are satisfied the organisation actively promotes and improves care recipients’ physical and mental health.

Examples of current or recent improvement activities related to health and personal care are described below.

Management reported a pain clinic was established in response to improving pain management for care recipients. As a result, 36 care recipients’ attend the pain clinic and care recipients’ reported satisfaction with pain management.

Following an audit, staff identified an opportunity to improve oral and dental care services. As a result, a denture marking kit was purchased and care recipients offered the opportunity for unlabelled dentures to be identified through the kit, and a seasonal toothbrush change process guides staff for toothbrush monitoring. Care recipients reported satisfaction with oral and dental service.


This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about health and personal care”.

Team’s findings


Organisational systems and processes identify and ensure the home achieves and maintains ongoing regulatory compliance in relation to care recipients’ health and personal care.

Clinical staff oversee initial and ongoing assessments of care recipients. Professional registrations for nursing staff and other health professionals are monitored. Internal and external audits ensure medication storage and administration complies with relevant guidelines. The organisation’s head office monitors any changes in legislation and alerts the service manager who disseminates the information to staff through electronic mail, meetings or


memoranda. There are policies and procedure for unexplained absences of care recipients. Care recipients and representatives reported care services are received in accordance with care and services for residential care services.



Team’s findings


Refer to expected outcome 1.3 Education and staff development for an overview of the home’s education and staff development systems and processes

Examples of education and training related to Standard 2 – Health and personal care are listed below.

Continence care

Dementia and behavioural management

Medication management and competencies

Oral and dental health

Oxygen, catheter care and suppository competencies

Palliative care and pain management

Parkinson’s management

Skin care and wounds.

2.4 Clinical care

This expected outcome requires that “care recipients receive appropriate clinical care”.

Team’s findings


Care recipients receive clinical care that is appropriate to their individual needs and preferences. When care recipients move into the home, registered nursing staff use validated assessment tools to assess care recipients’ clinical care needs. Care plans are developed to guide staff in the delivery of care recipients’ individual clinical care requirements, which are reviewed four-monthly and as required. General practitioners and relevant allied health practitioners regularly review care recipients. Clinical incidents are reported, actioned appropriately and analysed to identify risks, trends, opportunities for improvement and the need for staff education. Competency training and education is provided to ensure staff are competent in the delivery of care recipients’ clinical care. Care recipients and representatives reported they are consulted about care recipients’ clinical care and expressed satisfaction with the care recipients receive.


2.5 Specialised nursing care needs

This expected outcome requires that “care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”.

Team’s findings


Registered nurses plan and direct the implementation of actions to meet care recipients’ specialised nursing care needs. Individual care plans include information and directives from medical and allied health practitioners. The home provides specialised nursing care to care recipients who require complex wound care, oxygen therapy, continence management and behavioural management. Monitoring of specialised nursing care occurs through care plan review, internal audits and feedback from care recipients and representatives. Care recipients and representatives stated care recipients receive specialised nursing care according to their needs and preferences.

2.6 Other health and related services

This expected outcome requires that “care recipients are referred to appropriate health specialists in accordance with the care recipient’s needs and preferences”.

Team’s findings


Care recipients are referred to health specialists in accordance with their needs and preferences. A multidisciplinary team with the involvement of the general practitioner contributes to care recipients’ assessments and identifies the need for review by other health specialists. Referrals are made to other specialist services including the physiotherapist, occupational therapist, dietitian, speech pathologist and medical specialists. A podiatrist visits the home regularly and attends to the needs and preferences of care recipients.

Nursing staff access information and recommendations resulting from specialist reviews, and implement changes to care recipients’ care or medication. Care recipients and representatives stated they are satisfied with care recipients’ access to specialised health services.

2.7 Medication management

This expected outcome requires that “care recipients’ medication is managed safely and correctly”.

Team’s findings


Processes are established for the safe administration, storage, documentation and disposal of medications. Staff assist care recipients with their medications using a pre-packed administration system as per documented regime. Medication audits are undertaken regularly and medication incidents are reported, actioned and analysed monthly to identify any trends. A registered pharmacist conducts reviews of care recipients’ medications, and information is made available to the general practitioner. Care recipients and representatives stated they are satisfied care recipients’ medication are administered and managed safely.


2.8 Pain management

This expected outcome requires that “all care recipients are as free as possible from pain”.

Team’s findings


Clinical staff assess care recipients’ pain management needs when they move into the home and on an ongoing basis. A multidisciplinary approach to manage care recipients’ pain includes the general practitioner, registered nurse, enrolled nurse and allied health staff.

Specific pain assessment tools are utilised to assist in the identification of care recipients’ pain including verbal and non-verbal descriptions to identify signs of pain in care recipients with a cognitive or speech deficit. In addition to pain relieving medication, the use of alternative methods to manage care recipients’ pain includes heat packs, massage therapy and exercises. Care recipients and representatives stated staff manage care recipients’ pain effectively.

2.9 Palliative care

This expected outcome requires that “the comfort and dignity of terminally ill care recipients is maintained”.

Team’s findings


The homes approach to palliative care ensures the comfort and dignity of terminally ill care recipients is maintained in accordance with their needs and preferences. When care recipients move into the home or thereafter as preferred, discussion occurs with care recipients and their family on treatment decisions for future and end of life planning. When necessary, nursing staff develop an end of life care plan with strategies to manage the care recipients’ needs such as pain relief and personal care. Support is available through the general practitioner and external palliative care team. Staff reported families have been appreciative of the care and provision of services the home provides.

2.10 Nutrition and hydration

This expected outcome requires that “care recipients receive adequate nourishment and hydration”.

Team’s findings


Assessment of care recipients’ needs and preferences in relation to nutrition and hydration occurs when they move into the home and on an ongoing basis. Relevant staff are notified of care recipients’ meal preferences, special needs, allergies and cultural requirements.

Recording of each care recipient’s weight occurs during the initial assessment period, monthly thereafter and more frequently if required. The registered nurse notes variations and determines appropriate interventions and, if necessary, organises nutritional supplements.

The occupational therapist assesses care recipients for modified cutlery and crockery. Staff assist care recipients with their meals and drinks as assessed. Care recipients and


representatives stated they are satisfied care recipients’ nutrition and hydration needs are being met.

2.11 Skin care

This expected outcome requires that “care recipients’ skin integrity is consistent with their general health”.

Team’s findings


Assessment of care recipients’ skin integrity including a pressure injury risk assessment is completed when they move into the home. Care plans contain strategies and interventions for care staff to follow to maintain care recipients’ skin integrity, hair and nails. Care recipients who require wound care management have individual wound assessment and care plans to ensure continuity of care, and ongoing monitoring is recorded in the wound charts. The home has strategies to prevent skin breakdown and maintain skin integrity. Care staff report they inform nursing staff of any changes in care recipients’ skin integrity. Care recipients and representatives reported satisfaction with care recipients’ skin care provided by the home.

2.12 Continence management

This expected outcome requires that “care recipients’ continence is managed effectively”.

Team’s findings


Assessment of care recipients’ continence needs occurs when they move into the home and care plans are developed and reviewed four-monthly or as required. Care recipients receive assistance to manage their continence through a range of measures including scheduled toileting programs and the use of suitable continence aids, and their bowel elimination is recorded and interventions documented. Monitoring of care recipients’ urinary tract infections occurs and strategies are implemented as necessary. Staff reported they have sufficient supplies and training to enable them to manage care recipients’ continence needs. Care recipients and representatives reported staff are effective in meeting care recipients’ continence needs.

2.13 Behavioural management

This expected outcome requires that “the needs of care recipients with challenging behaviours are managed effectively”.

Team’s findings


Assessment of care recipients’ behaviours occurs when they move into the home. Individual care plans identify interventions to assist in minimising or preventing challenging behaviours and their effects on others. Referrals to specialist services including the mental health team are made in consultation with the general practitioner, and recommended behaviour management strategies are implemented and monitored for effectiveness. Staff attend training in dementia care and behaviour management, and report on strategies they use to manage the needs of care recipients with challenging behaviours. Care recipients and their representatives stated care recipients are not adversely affected by the behaviour of others.


2.14 Mobility, dexterity and rehabilitation

This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.

Team’s findings


When care recipients move into the home, registered nursing staff, the physiotherapist and occupational therapist assess each care recipient’s level of mobility and dexterity and falls risk. Care recipients are encouraged to maintain their mobility and dexterity by participating in the home’s physiotherapy and activity programs including individual and group exercise programs and physical activities to improve independent movement. Appropriate seating and other aids are available to assist mobility and maintain independence. An incident reporting system includes the analysis of incidents to identify trends and implement strategies to reduce care recipient falls. Care recipients and representatives reported they are satisfied with the way staff encourage and support care recipients to maintain their mobility.

2.15 Oral and dental care

This expected outcome requires that “care recipients’ oral and dental health is maintained”.

Team’s findings


Registered nurses assess and evaluate care recipients’ oral and dental health care needs when they move into the home, annually and as required. Care plans guide staff to assist care recipients to maintain their oral and dental hygiene including assisting them to clean their teeth or dentures and, if necessary, regular mouth washes. Care recipients have regular access to the visiting dentist who conducts dental examinations and treatments. Staff reported they undertake oral care for care recipients, and there is a process to ensure they have appropriate oral health equipment and products. Care recipients and representatives reported they are satisfied with the oral and dental care provided to care recipients by staff.

2.16 Sensory loss

This expected outcome requires that “care recipients’ sensory losses are identified and managed effectively”.

Team’s findings


Registered nurses assess and evaluate care recipients’ sensory losses in all five senses when they move into the home, annually or in response to staff feedback. Care plans include strategies to manage care recipients’ sensory losses and to maximise each care recipient’s independence and interaction in daily living. The activity program includes sensory activities developed by the occupational therapist. Care recipients have access to an optometrist and audiologist through referral if required. Staff described strategies they use to assist care recipients with their sensory losses and to manage their sensory devices. Care recipients and representatives stated they are satisfied with the assistance care recipients receive to manage their sensory loss.


2.17 Sleep

This expected outcome requires that “care recipients are able to achieve natural sleep patterns”.

Team’s findings


Care recipients’ settling routines are recorded when they move into the home and their sleep patterns are assessed. Care recipients’ individualised care plans include their settling routines and sleep management strategies. The home provides a quiet and secure environment. Night sedation medication is administered as prescribed and is regularly reviewed. Other strategies include repositioning, pain management and the offer of snacks and drinks. Care recipients and representatives reported they are satisfied with the way the staff assist care recipients to achieve a restful sleep at night.


Standard 3 – Care recipient lifestyle

Principle: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community.



Team’s findings


Refer to expected outcome 1.1 Continuous improvement for an overview of the home’s continuous improvement system.

In relation to care recipient lifestyle, care recipient meetings and care recipient surveys are used to gather suggestions and trends. Feedback is regularly recorded and evaluated from lifestyle and care activities. Staff encourage and support care recipients and others to provide feedback and suggestions.

An example of current or recent improvement activity related to Standard 3 – Care recipient lifestyle is described below.

Following a review of the lifestyle program, staff identified an opportunity to improve the emotional support to care recipients. As a result, a tool was implemented to capture relevant information to share with staff the life story of care recipients for better understanding of their needs. Staff reported they receive education on the use of the tool and has led to a better understanding of the care recipients.


This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about care recipient lifestyle”.

Team’s findings


Care recipients are informed about their rights and responsibilities in information provided to them when they move into the home. Information updates are advised in writing and discussed at relevant meetings. The home provides each care recipient with an agreement outlining fees, level of care and services and tenure arrangements. There are policies and procedures for the compulsory reporting of care recipient assault. Staff are informed of changes in legislation relevant to care recipient lifestyle through training, memoranda and meetings. Care recipients and representatives reported they are consulted in regard to making decisions about services and are informed when changes in provision of care arise.




Team’s findings


Refer to expected outcome 1.3 Education and staff development for an overview of the home’s education and staff development systems and processes.

Examples of education and staff development undertaken relevant to Standard 3 – Care recipient lifestyle are listed below.

Emotional support

Restraint management.

3.4 Emotional support

This expected outcome requires that "each care recipient receives support in adjusting to life in the new environment and on an ongoing basis".

Team’s findings


Care recipients receive support on entry into the home and on an ongoing basis. Activity and direct care staff orientate new care recipients and representatives to the home and provide support in the transition to the residential community living environment. Care recipients are assessed during the settling-in period which assists in identifying emotional support needs. Care plans are developed to guide staff interactions and are reviewed regularly and updated as needed to ensure each care recipient’s needs are being met. Care recipients are encouraged to personalise their rooms, and visits by care recipients’ families and friends are welcomed and encouraged. Attendance at individual group therapy sessions and activities is monitored monthly to identify care recipients at risk of social isolation. Care recipients and representatives interviewed reported they are satisfied care recipients’ emotional needs are being met.

3.5 Independence

This expected outcome requires that "care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service".

Team’s findings


Care recipients are assisted to achieve maximum levels of independence and maintain links with the community within and outside the home. An occupational therapist and a physiotherapist assess each care recipient’s functional abilities when they move into the home and regularly thereafter. Care plans are developed to reflect individuality and to ensure care recipients are enabled to make choices that promote independence. Therapeutic and exercise programs are scheduled to aid care recipients’ functional abilities and assistive devices for


mobility. Meals, communication and toileting are provided as required. Staff interviewed described strategies to maintain care recipients’ independence in accordance with individual abilities. Care recipients and representatives interviewed stated they are satisfied with the assistance provided to maintain independence according to care recipients’ needs and preferences.

3.6 Privacy and dignity

This expected outcome requires that "each care recipient’s right to privacy, dignity and confidentiality is recognised and respected".

Team’s findings


Each Care recipient’s right to privacy, dignity and confidentiality is recognised and respected. The care recipients’ information package includes relevant statements and brochures on privacy, consent and disclosure of information. An initial and ongoing assessment process identifies the care recipients’ need for privacy, dignity and confidentiality that includes continence, sensory loss, cultural, and palliative care and cognitive considerations. The home’s environment promotes privacy, including the provision of quiet indoor and outdoor areas for care recipients to meet families and visitors. Staff interviewed demonstrated knowledge of practices to maximise the privacy of care recipients and maintain confidential information. Care recipients and representatives interviewed reported care recipients’ privacy, dignity and confidentiality are maintained and respected.

3.7 Leisure interests and activities

This expected outcome requires that "care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them".

Team’s findings


There are processes to ensure care recipients are encouraged and supported to maintain their interests and activities. When care recipients first move into the home they are assessed by the occupational therapist and their identified interests are used to develop individual therapy care plans. The activity programs include a range of cognitive, gross motor, physical, sensory and social group activities as well as special and cultural events and community bus outings. Therapy staff and volunteers provide one-on-one activities for those care recipients who are unable, or who choose not to participate in group activities. Care recipients and representatives reported they are satisfied with the range of activities offered to care recipients.

3.8 Cultural and spiritual life

This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".

Team’s findings


The therapy team collects information about the care recipients’ cultural and spiritual needs and undertake an assessment when care recipients move into the home. This information is


updated following a care and lifestyle services review and communicated to relevant staff for care/service delivery. The therapy team maintains a list of care recipients’ countries of origin and preferred language, liaises with multicultural/volunteer associations and organises cultural theme days throughout the year. The home has access to a chaplain who provides religious services for all dominations and community volunteers giving emotional support to care recipients as required. Care recipients and representatives reported they are satisfied with the cultural and spiritual life provided at the home.

3.9 Choice and decision-making

This expected outcome requires that "each care recipient (or his or her representative) participates in decisions about the services the care recipient receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people".

Team’s findings


Management and staff encourage and support care recipients and their representative individual choices and decisions about care and service delivery. Relevant staff assess care recipients’ individual needs, abilities and preferences across areas of care, lifestyle and service delivery when moving into the home and on a regular basis thereafter. The home conducts meetings and case conferences to provide care recipients and representatives with a forum to express views and participate in decisions about care and services. Complaints mechanisms are available to care recipients and their representatives, and authorised representatives make decisions on behalf of care recipients who are unable to act for themselves. Staff interviewed gave examples of strategies for supporting care recipients’ individual preferences, including sleep routines, choice of meals/drinks, care interventions and participation in activities as well as refusal. The home uses feedback mechanisms, satisfaction surveys and evaluations of programs to monitor the effectiveness of care recipients’ choice and preferences. Care recipients and representatives interviewed stated care recipients are encouraged and are able to exercise choice and control over care and services they receive.

3.10 Care recipient security of tenure and responsibilities

This expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities".

Team’s findings


There are processes to ensure care recipients have secure tenure within the home and understand their rights and responsibilities. The home has an admission process to assist care recipients when they move into the home. Care recipients and/or representative receive a care recipient information package that includes an agreement and handbook which provides information pertaining to care recipients’ rights and responsibilities, complaints mechanisms, security of tenure and specified level of care services. External advocacy and guardianship administration are used as required. Consultation is undertaken with care recipients and representatives prior to room transfers within the home and changes to the provision of services. Staff are provided with education and training regarding care recipients’ rights and responsibilities. Care recipients and representatives reported they are informed of fee changes and are satisfied care recipients have security of tenure at the home.


Standard 4 – Physical environment and safe systems

Principle: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.



Team’s findings


Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes.

Examples of current or recent improvement activities related to Standard 4 – Physical environment and safe systems are described below.

Following feedback, management identified an opportunity to improve the living environment for care recipients. As a result, a renovation project was commenced with two of the six houses being freshly painted and furniture, vinyl and carpets replaced. Management reported the completion of the other houses will occur in the next few months and care recipients and representatives reported satisfaction with the changes.

Management identified an opportunity to improve the laundry services. As a result, laundry duties have been re-allocated from care staff to dedicated laundry staff who operate the laundry six days a week. Staff reported a duty statement has been created, duties adjusted according to the processes trialled and implemented over the next few months. Management reported a clothes labeller will be purchased to support the labelling of care recipients’ clothing following a complaint from a care recipient of lost laundry.


This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems”.

Team’s findings


The home has management systems to ensure ongoing regulatory compliance in relation to the physical environment and safe systems. Workplace building, catering and fire emergency preparedness are routinely inspected and audited. Safety data sheets for chemicals used are available to staff at all times and kept updated, and infection control guidelines are available. The home has a food safety program to provide staff guidance. Interviews with staff confirmed their knowledge of regulatory compliance requirements




Team’s findings


Refer to expected outcome 1.3 Education and staff development for an overview of the home’s education and staff development systems and processes.

Examples of education and staff development undertaken relevant to Standard 4 – Physical environment and safe systems are listed below.

Chemical safety

Fire and emergency procedures

Food safety

Infection control/hand hygiene

Manual handling

Occupational health and safety.

4.4 Living environment

This expected outcome requires that "management of the residential care service is actively working to provide a safe and comfortable environment consistent with care recipients’ care needs".

Team’s findings


Management and staff provide a safe and comfortable environment consistent with the care recipients’ needs. The home provides care recipients with single rooms with an ensuite, and the living environment is equipped to assist care recipients with their independence, comfort, privacy and security. Care recipients and their families have access to internal and external private and communal areas for meals, social interactions and activities. Allied health professionals conduct further assessments for care recipients identified at risk of falls and altered skin integrity, and establish environmental and safety strategies to manage such risks. There are processes to ensure the environment is well maintained, clean, clutter and odour free. Management undertakes satisfaction surveys and environmental audits, and takes actions in response to identified issues/suggestions or potential hazards. Staff described ways they manage and report environmental hazards. Care recipients and representatives expressed their satisfaction with temperature, safety and comfort, and reported management are actively working to provide a comfortable living environment.


4.5 Occupational health and safety

This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".

Team’s findings


Management and staff actively provide a safe working environment that meets regulatory requirements. Staff are oriented to their occupational health and safety responsibilities and organisational safety policies and procedures guide and direct staff practice. Management and staff regularly assess the physical environment, report risks, identify potential and actual hazards and analyse accidents and incidents. The home has a process for tagging of electrical appliances and scheduling maintenance. Staff receive information on their occupational health and safety responsibilities during induction, meetings and memoranda. Staff reported they identify and report hazards and accidents, and management is proactive in providing a safe working environment.

4.6 Fire, security and other emergencies

This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks".

Team’s findings


The home has systems and processes to maintain a safe environment that reduces the risk of emergencies, fires and security breaches. Approved professionals carry out regular testing of fire detection systems, firefighting equipment and exit lighting. The home has a plan to guide staff in situations that prevent the continuity of business such as a fire threat, and emergency procedures contain an updated care recipient mobility evacuation list. Evacuation maps and signage show orientation and information regarding exit routes and location of firefighting equipment and are located throughout the home. Staff described the home’s security systems and emergency procedures and reported there are processes to check and tag new and existing electrical appliances to identify and resolve electrical hazards. Care recipients, representatives, contractors and visitors sign in and out to ensure awareness of who is in the building. Care recipients and representatives are informed of what to do if they hear a fire alarm via the resident handbook, newsletters, posters and meetings.

4.7 Infection control

This expected outcome requires that there is "an effective infection control program".

Team’s findings


The management team and dedicated clinical staff coordinate the home’s effective infection control program. Policies, guidelines, a food safety program and outbreak kits are available in the home to assist staff. Staff log care recipients’ infections electronically, and trained staff carry out treatments as instructed by the general practitioner and as per the care recipients’ wound management plans. Management delivers a monthly report that includes an analysis and trends to improve care. Equipment and signage are used to lessen the risk of infection. The home routinely conducts infection control audits with focus on environment, linen handling


management and hand washing. Mandatory training includes infection control and staff were able to provide examples of infection prevention strategies. Care recipients and representatives reported satisfaction with the home’s infection control program.

4.8 Catering, cleaning and laundry services

This expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment".

Team’s findings


Systems and processes for catering, cleaning and laundry enhance the care recipients’ quality of life and meet the care recipients’ needs. A catering service with qualified chefs and kitchen staff cook meals onsite and make up nourishing snacks and drinks. There is a four weekly rotating menu that provides care recipients with meal choices, and changes to the menu occur in response to care recipients’ feedback. The home has two dining rooms and provides care recipients with a dining experience that includes table settings and foods of interest being served. Scheduled task lists and duties in their provision of services guide laundry and cleaning staff, and the maintenance program has a provision for external services support. There is a marking and sorting system to prevent loss of linen and clothes. All hospitality services encompass the home’s food safety and infection control requirements, and management monitors for quality via feedback, audits and surveys. Care recipients and representatives reported satisfaction with the food, cleaning and laundry services provided.

RSL War Veterans Home Mandurah - Aged Care Quality€¦ · RSL War Veterans Home Mandurah 7154...

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Transcript of RSL War Veterans Home Mandurah - Aged Care Quality€¦ · RSL War Veterans Home Mandurah 7154...